Modifier 22 Could Help Save This Lap-to-Open Gyn Surgery

Wed, Feb 15, 2017


laparoscopic gynecological procedure

Whether to code lysis of adhesions during a gynecological procedure is a question that comes up again and again.

I’ve talked before about how removing adhesions is generally an expected part of the procedure, but exceptional cases may merit the use of modifier 22 (Increased procedural services) on the surgery code.

A new take on this question is how to handle coding for a surgery that converts from laparoscopic to open because of adhesions. Here’s an example from Ob-Gyn Coding Alert with some bonus tips straight from the National Correct Coding Initiative manual (NCCI manual or CCI manual, for short).

Start With This Sling Example

Consider the example of an ob-gyn surgeon who begins a laparoscopic sling procedure described by 51992 (Laparoscopy, surgical; sling operation for stress incontinence [e.g., fascia or synthetic]).

The surgeon tries to remove massive adhesions affecting the bowel, pelvic sidewall, fallopian tubes, and ovaries. The documentation describes the adhesions as extensive, dense, very adherent, and containing a blood supply. After an hour, the surgeon decides that converting the surgery to an open procedure is the best decision for the patient. The correct code for the open procedure is 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). (By the way, have any of you ever wished CPT® would update code descriptors like 57288 to include the term “open” when that’s what the code represents? There’s a word for that sort of change: retronym.)

Here Are the General CCI Rules

Chapter I: The first chapter of the CCI manual covers General Correct Coding Policies.

Chapter 1, Section B, Coding Based on Standards of Medical/Surgical Practice, lists lysis of adhesions as one of the services integral to a large number of procedures.

Translation: It’s not surprising that CCI edits bundle lysis codes into so many surgeries.

Section C, Medical/Surgical Package, addresses the issue of coding for laparoscopic procedures converted to open procedures in subsections 10 and 11:

  • 10. “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported.”
  • 11. “If a laparoscopic procedure fails and is converted to an open procedure, the physician should not report a diagnostic laparoscopy in lieu of the failed laparoscopic procedure.”

Translation: If a laparoscopic approach fails and the surgeon switches to an open procedure to complete the surgery, then you should report only the open procedure. And don’t try to get around the rule by coding the lap work as a diagnostic service.

Chapter VII: The seventh chapter applies to surgery codes in the 50000-59999 range, including female genital surgery. Section F, Laparoscopy, subsection 4, supports what the first chapter had to say.

  • 4. “If a laparoscopic procedure fails and is converted to an open procedure, only the open procedure may be reported. Neither a surgical laparoscopy nor a diagnostic laparoscopy code should be reported with the open procedure code when a laparoscopic procedure is converted to an open procedure.”

Full disclosure: If the lap service was truly diagnostic, CCI applies a different rule. According to Section F.1, “If a laparoscopy is performed as a ‘scout’ procedure to assess the surgical field or extent of disease, it is not separately reportable. If the findings of a diagnostic laparoscopy lead to the decision to perform an open procedure, the diagnostic laparoscopy may be separately reportable.” You may use modifier 58 (Staged or related procedure …) in those cases, the manual says. “The medical record must indicate the medical necessity for the diagnostic laparoscopy.”

Apply the Rules to Our Case

We know the correct code to report for our encounter is the open procedure code 57288. Based on all of our CCI pointers listed above, you can’t report laparoscopic procedure code 51992 for this lap-to-open surgery, so your best option for reporting the intense laparoscopic work is to append modifier 22 to 57288.

Using modifier 22 is sure to trigger a manual review by the payer, so check the documentation you submit to confirm it clearly shows the unusually difficult nature of the case and compares the time and work this case required to the time and work a typical case requires.

How About You?

What are your tips for submitting modifier 22 claims that get paid and meet compliance rules?

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ASC Payment: Ride the Ups and Downs of New CPT® 2017 Spine Codes

Fri, Feb 10, 2017


spine illustration

Ambulatory surgical centers (ASCs) are their own special animal, and discovering which procedures Medicare will cover in an ASC can take some investigation. Here’s a look at the ASC fee schedule data for the spine codes CPT® added in 2017.

Keep in mind: This information applies to Medicare. You may be able to negotiate different rules with private payers.

No Joy for Biomechanical Device Insertion Codes

CPT® 2017 introduced three new add-on codes for biomechanical device insertion:

  • +22853 for insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) in conjunction with interbody arthrodesis
  • +22854 for insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) in conjunction with interbody arthrodesis
  • +22859 for insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh, methylmethacrylate) without interbody arthrodesis.

History: These codes replace now-deleted code 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), methylmethacrylate] to vertebral defect or interspace [List separately in addition to code for primary procedure]). In 2016, Medicare listed 22851 as excluded from payment in ASCs.

No separate payment: Medicare’s 2017 ASC addendum AA lists the payment indicator for all three new add-on codes as N1, which means “Packaged service/item; no separate payment made.”

Tip: The primary service codes paired with these add-on codes may be reportable in the ASC. For example, CPT® lists 63030 as one of the possible primary codes for +22853. Medicare’s 2017 payment rate for 63030 is $2,651.09.

Find a Mixed Bag for 22867-22870

CPT® 2017 also introduced four new codes for insertion of lumbar interlaminar/interspinous process stabilization/distraction devices: 22867-+22870. These codes replace now-deleted codes 0171T and +0172T (Insertion of posterior spinous process distraction device [including necessary removal of bone or ligament for insertion and imaging guidance], lumbar …).

In 2016, the Medicare ASC rate for 0171T was $7,886.65. (Add-on code +0172T wasn’t listed.)

Separate payment for some: Primary codes 22867 and 22869 have payment indicator J8, which means “Device-intensive procedure; paid at adjusted rate.” The final payment rate for each is $10,521.55.

The add-on codes +22868 and +22870 have indicator N1, which, as mentioned above, means there is no separate payment because the service is packaged.

Size Up the New Rate for Endoscopic Lumbar Decompression

A final new CPT® 2017 code for the spine is 62380 (Endoscopic decompression of spinal cord, nerve root[s], including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar).

In 2016, this endoscopic decompression would have been best represented by an unlisted procedure code.

Separate payment: In 2017, the payment indicator for 62380 is J8, so it’s priced as a device-intensive procedure. The rate is $3,574.44.

What About You?

Do you code for ASCs? Do you tend to agree with Medicare’s list of covered procedures?

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Don’t Overlook These 4 Tips for Coding Dialysis Circuit Services in 2017

Tue, Feb 7, 2017


dialysis circuit coding

There are pros and cons to getting two full pages of CPT® guidelines on how to use the nine new dialysis circuit codes in 2017. You get lots of helpful information, but the really important pointers risk getting lost in the crowd. Don’t let these gems from the guidelines and code-level notes pass you by.

Tip 1: Heed the Hierarchy Before You Code

The new codes are in the range 36901 to +36909. You’ll notice that the codes are built on progressive hierarchies, meaning you choose one code from the group based on the highest level service performed. For example, take a look at how CPT® structures 36901 to 36903:

  • 36901 = Diagnostic angiography
  • 36902 = Diagnostic angiography + peripheral segment angioplasty
  • 36903 = Diagnostic angiography + peripheral segment angioplasty + peripheral segment stenting.

Smart move: Before you make your final selection, make a point of reviewing the parenthetical notes with the code or codes you’re reporting. You’ll find helpful hints like a rule forbidding you from reporting diagnostic code 36901 with any other code in the range 36902-36906.

Tip 2: Get Clear on Both Upper and Lower Extremity Segments

The guidelines define the “peripheral dialysis segment” and the “central dialysis segment.” Within each of those definitions, be sure to study how each term applies to the upper and lower extremities.

Upper extremity:

  • Central segment: Involves the veins central to the axillary and cephalic veins, such as the subclavian and innominate (brachiocephalic) veins through the superior vena cava
  • Peripheral segment: Extends through the axillary vein or the cephalic vein if the patient has cephalic vein outflow

Lower extremity:

  • Central segment: Includes veins central to the common femoral, such as the external and common iliac veins through the inferior vena cava (IVC)
  • Peripheral segment: Extends through the femoral vein

Tip 3: Know When to Code More and Less

More: Occasionally, usually when there’s a new or failing arteriovenous fistula (AVF), the doctor may determine vascular access requires ultrasound guidance. You may report +76937 in those cases.

Less: If the physician performs supervision and interpretation of angiography through an existing access or catheter-based arterial access, you should append modifier 52 (Reduced services) to 36901, the code for diagnostic angiography of the dialysis circuit.

Tip 4: Don’t Make Assumptions About Add-On Codes

The new range includes three add-on codes. You might assume that the primary codes for these add-on options are limited to the other codes in the dialysis circuit range, but that isn’t true for two of the codes.

Code +36907 is for angioplasty in the central dialysis segment and +36908 is for stenting (and any angioplasty) in the central dialysis segment.

The primary codes for both of those add-on codes do include dialysis circuit codes 36901-36906. But don’t miss that you also may report +36907 or +36908 in conjunction with 36818-36833, which includes services like AVF creation and revision.

The third add-on code, +36909, represents permanent embolization or occlusion of the dialysis circuit. The appropriate primary codes for that service are 36901-36906.

How About You?

Do you code for dialysis services? Do you prefer the new codes or the ones you used in 2016? Are your claims being affected by the erroneous CCI edits bundling the dialysis circuit codes with moderate sedation?

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Haven’t Started MACRA QPP Prep? There’s Still Time!

Fri, Feb 3, 2017


Groundhog Day MACRA prep

Groundhog Day has come and gone, and Punxsutawney Phil has declared six more weeks of winter. That gives you plenty of inside time to focus on getting up to speed on MACRA so you can participate in 2017.

Remember: With CMS’s Pick Your Pace approach to the Merit-based Incentive Payment System (MIPS), it’s OK if you weren’t ready to hit the ground running on January 1. Submitting Quality Payment Program (QPP) data for the full year offers your best chance for a bonus, but even a little effort will go a long way to help you avoid a penalty. With that in mind, let’s take a look at QPP quality measures.

Narrow Your 270 Options Fast

CMS offers a QPP quality measures page with a tool that helps you search the 270 measures for the ones that apply to you. You can filter based on high or low priority, data submission method (such as claims or registry), and specialty measure set (your physician’s specialty).

For example, if you filter to see the high priority measures for orthopedics, here are some of the measures you’ll find in the results that are most likely to apply to your orthopedic practice:

  • Documentation of Current Medications in the Medical Record
  • Functional Status Assessment for Total Hip Replacement
  • Functional Status Assessment for Total Knee Replacement
  • Osteoarthritis (OA): Function and Pain Assessment
  • Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
  • Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
  • Total Knee Replacement: Shared Decision Making: Trial of Conservative (Non-surgical) Therapy
  • Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
  • Use of Imaging Studies for Low Back Pain.

As a warning on the page states, the tool is just for information, so don’t assume the information in your search results is accurate. Confirm the measure requirements in the official documents. You can find Quality Measures Specifications and Quality Measures Specifications Supporting Documents on the QPP education page.

What Do Quality Measures Look Like?

The Quality part of MIPS replaces the Physician Quality Reporting System (PQRS), so you may (or may not) be pleased to know the formatting of the measures will look familiar. That means all that time you spent learning about denominators (the population evaluated) and numerators (the patients within that population who met measure requirements) won’t go to waste.

In the Quality Measures Specifications files on the QPP education page (linked in the previous section), also watch for a flow chart, written instructions, and sample calculations with the measure to help guide you through the process.

How About You?

What has helped you learn about MACRA? Do you plan to submit data for the full year?

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Lucky Number 3! Don’t Miss This $33 Increase for Intubation Code 31500

Tue, Jan 31, 2017


31500 emergency intubation

The 2017 Medicare Physician Fee Schedule (MPFS) final rule estimated a 0 percent impact on total allowed charges for emergency medicine this year. But did you catch the nice boost for 31500 (Intubation, endotracheal, emergency procedure)? Here are the details on that change for those of you who enjoy a nice fee schedule adventure.

Catching 31500 Coding Opportunities Pays Off This Year

In 2016, Medicare identified emergency intubation code 31500 as potentially misvalued. After surveying specialty societies, the RUC recommended 3.00 work RVUs for 31500. In 2016, the code had 2.33 work RVUs, so 3.00 would be an increase worth noting.

Definition time: In case you need some help deciphering that last paragraph, RUC refers to the American Medical Association/Specialty Society Relative (Value) Update Committee. And work RVUs are the relative value units (RVUs) assigned to the physician work (time and intensity) involved in completing the service described by the code. When you add together the work RVUs, practice expense RVUs, and malpractice RVUs assigned to a code, and then multiply that sum by the conversion factor (35.8887 in 2017), you get the national rate Medicare pays for a code. The final amount you actually receive will be adjusted further based on elements like geography and possibly the modifiers and other codes you assign.

Back to 31500: In response to the RUC suggestion of 3.00, Medicare said 2.66 work RVUs seemed more accurate, suggesting the time and intensity were similar to 65855 (Trabeculoplasty by laser surgery). That little tidbit is on page 80285 of the 2017 MPFS final rule.

Commenters told Medicare that the emergent nature of 31500 meant glaucoma treatment code 65855 wasn’t a fair comparison. After considering that comment and the fact that the recent surveys showed an intraservice time of 10 minutes for 31500 (instead of the 5 minutes used for previous 31500 pricing), Medicare decided in the final rule to go with 3.00 work RVUs for 31500.

That increase along with some smaller increases to the practice expense RVUs and malpractice RVUs means that the 2016 national rate of $113.14 got lifted to $146.07 in 2017. That’s about $33 more! All you need to do to collect that extra reimbursement is to continue to code emergency endotracheal intubation correctly based on the documentation from the provider.

How About You?

Do you code for emergency medicine? Are there any other codes you feel are misvalued?

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CCI Errors: Some Moderate Sedation Pay May Be Delayed Until April

Fri, Jan 27, 2017


CCI Edit Alert


Seeing the new 2017 moderate sedation codes appear among the 99,490 new National Correct Coding Initiative (NCCI or CCI) edits wasn’t really a surprise, but a handful of those edits just might cause you some headaches all the same. The culprit? Modifier indicators. The good news? There should be a correction in the next version.

Here’s the Problem for Moderate Sedation

According to an announcement sent out by Medicare contractor National Government Services (NGS), the NCCI contractor has reported an error in the Jan. 1, 2017, version of the edits.

New moderate sedation codes 99151-99153, which apply when a provider performs both the moderate sedation and the procedure, were bundled incorrectly into more than 30 procedure codes. The problem edits have a modifier indicator of 0, which means you can’t override the edits.

Here Are the Codes Involved

NGS lists the following codes as the ones impacted by the issue:

  • 0424T-0436T for services related to neurostimulator systems for treatment of central sleep apnea
  • 0459T-0461T for implanted aortic counterpulsation ventricular assist device services
  • 36901-36909 for dialysis circuit services
  • 37246-37249 for transluminal balloon angioplasty
  • 43210 for esophagogastroduodenoscopy with fundoplasty
  • 45399 for an unlisted colon procedure
  • 45990 for an anorectal exam.

The announcement also lists intracranial balloon dilatation code 61640, but the January 2017 CCI edits do not include edits for 61640 with 99151-99153. There are edits bundling moderate sedation codes 99155-99157 into 61640 with a modifier indicator of 0. Keep in mind that 99155-99157 are reported by a provider who administers moderate sedation but does not perform the related procedure.

Total speculation: It’s possible including 61640 was a typo, and NCCI meant to identify another code, such as 61645 for intracranial thrombectomy and thrombolysis. Code 61645 is currently bundled with 99151-99153 with a modifier indicator of 0. But that’s a guess, and you shouldn’t base your coding on a guess. Watch for an update to this post when more information becomes available from Medicare.

[Update: The erroneous error involves 61645 and not 61640. You can see the complete listing of codes in a letter from the CCI contractor to the American College of Radiology (ACR).]

Here’s How You Should Handle the Issue

The plan is for the errors to be corrected in the next version of NCCI, which will be effective April 1, 2017.

The NGS announcement states that NCCI recommends delaying submission of you claims for 99151-99153 when performed with one of the problem procedure codes. Once the next version is implemented April 1, you can submit the delayed claims for payment. If you do submit these claims before the April correction, you can appeal the denial after April 1.

How About You?

Do these errors affect your claims? Will you delay submitting the codes, or will you submit them and appeal denials that come in

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Are You a Vaccine Guidelines Ace? Test Yourself

Tue, Jan 24, 2017


vaccination CPT quiz

Vaccination coding crosses many specialties. See if you’ve got what it takes to code these common services. Answer the questions below based on the CPT® guidelines for vaccine immunization codes.

Take the Quiz

1. True or false: You may report vaccine immunization administration codes 90460, 90461, and 90471-90474 in addition to the vaccine and toxoid codes 90476-90749.

2. Which of the following codes is appropriate for IM vaccine administration not accompanied by face-to-face counseling by a physician (or other qualified health care professional) for a patient over 18 years of age?

  • A. 90460
  • B. 90461
  • C. 90471

3. Documentation shows a significant separately identifiable 99213 service performed at the same encounter as the vaccine administration. Do CPT® guidelines allow you to report the E/M service in addition to the vaccine admin?

  • A. Yes
  • B. No
  • C. The guidelines don’t specify

4. Code 90460 applies to the “first or only component of each vaccine or toxoid administered.” Which of the following is true?

  • A. A component refers to all antigens in a vaccine that prevent disease(s) caused by any number of organisms.
  • B. Multi-valent antigens against a single organism are considered a single component of vaccines.
  • C. Adjuvants contained in vaccines are considered to be component parts of the vaccine.

Check Your Answers

1. The correct answer is True. You may report both an admin code and a vaccine/toxoid code for vaccinations. Keep in mind that Medicare requires G codes for administration. For instance, for pneumococcal vaccine admin, you should report G0009 (Administration of pneumococcal vaccine).

2. The correct answer is C for 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]). The answer isn’t obvious from the descriptor for 90471, but the guidelines support this choice, and both 90460 and +90461 have descriptors that begin with “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …”

3. The correct answer is A. The CPT® guidelines indicate you may report office and other outpatient services (99201-99215), consults (99241-99245), emergency department services (99281-99285), and preventive medicine services (99381-99429) in addition to the vaccine admin code. Keep in mind that payers may not follow CPT® guidelines. For example, Medicare CCI edits bundle established patient office visit code 99211 (sometimes called a nurse visit code) into codes like 90471.

4. The correct answer is B. The other two are not true. Answer A would be true if it stated “caused by one organism” instead of saying “caused by any number of organisms.” Option C would be true if it stated adjuvants “are not considered to be component parts.”

How About You?

Do you code for vaccinations? How do you keep up with the changing codes and different payer rules?

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HCPCS 2017: Which Supplies & Services Made the Leap Away From C Codes?

Fri, Jan 20, 2017


HCPCS 2017 C code changes

In the world of HCPCS, C codes are a special bunch. CMS initially created C codes for use on Hospital Outpatient Prospective Payment System claims, but rule changes now allow a limited number of other providers to use the codes, too, such as Critical Access Hospitals and Indian Health Service hospitals.

Restrictions on reporting C codes matter because they aren’t intended for physician use. And that adds some complexity to coverage and reimbursement.

Below are 2016 C codes that moved to other sections in HCPCS 2017. Having a non-C code doesn’t automatically equate to coverage or reimbursement, but it’s worth checking whether your payer will cover the new codes relevant to you. The codes are listed under the range names provided by HCPCS 2017.

Chemotherapy Drugs

  • Daratumumab
    • 2016: C9476, Injection, daratumumab, 10 mg
    • 2017: J9145, Injection, daratumumab, 10 mg
  • Elotuzumab
    • 2016: C9477, Injection, elotuzumab, 1 mg
    • 2017: J9176, Injection, elotuzumab, 1 mg
  • Irinotecan liposome
    • 2016: C9474, Injection, irinotecan liposome, 1 mg
    • 2017: J9205, Injection, irinotecan liposome, 1 mg
  • Necitumumab
    • 2016: C9475, Injection, necitumumab, 1 mg
    • 2017: J9295, Injection, necitumumab, 1 mg
  • Talimogene laherparepvec
    • 2016: C9472, Injection, talimogene laherparepvec, 1 million plaque forming units (PFU)
    • 2017: J9325, Injection, talimogene laherparepvec, per 1 million plaque forming units
  • Trabectedin
    • 2016: C9480, Injection, trabectedin, 0.1 mg
    • 2017: J9352, Injection, trabectedin, 0.1 mg

Clotting Factors

  • Idelvion
    • 2016: C9139, Injection, factor IX, albumin fusion protein (recombinant), Idelvion, 1 I.U.
    • 2017: J7202, Injection, factor IX, albumin fusion protein, (recombinant), Idelvion, 1 I.U.
  • Nuwiq
    • 2016: C9138, Injection, factor VIII (antihemophilic factor, recombinant) (Nuwiq), 1 I.U.
    • 2017: J7209, Injection, factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 I.U.
  • Pegylated factor VIII
    • 2016: C9137, Injection, factor VIII (antihemophilic factor, recombinant) pegylated, 1 I.U.
    • 2017: J7207, Injection, factor VIII, (antihemophilic factor, recombinant), pegylated, 1 I.U.

Diagnostic and Therapeutic Radiopharmaceuticals

  • Choline C-11
    • 2016: C9461, Choline C 11, diagnostic, per study dose
    • 2017: A9515, Choline C-11, diagnostic, per study dose up to 20 millicuries

Drugs Administered by Injection

  • Argatroban
    • 2016: C9121, Injection, argatroban, per 5 mg
    • 2017: J0883, Injection, argatroban, 1 mg (for non-ESRD use)
  • Aripiprazole lauroxil
    • 2016: C9470, Injection, aripiprazole lauroxil, 1 mg
    • 2017: J1942, Injection, aripiprazole lauroxil, 1 mg
  • Mepolizumab
    • 2016: C9473, Injection, mepolizumab, 1 mg
    • 2017: J2182, Injection, mepolizumab, 1 mg
  • Reslizumab
    • 2016: C9481, Injection, reslizumab, 1 mg
    • 2017: J2786, Injection, reslizumab, 1 mg
  • Sebelipase alfa
    • 2016: C9478, Injection, sebelipase alfa, 1 mg
    • 2017: J2840, Injection, sebelipase alfa, 1 mg

Miscellaneous Drugs

  • Ciprofloxacin otic suspension
    • 2016: C9479, Instillation, ciprofloxacin otic suspension, 6 mg
    • 2017: J7342, Installation, ciprofloxacin otic suspension, 6 mg
  • Hymovis
    • 2016: C9471, Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
    • 2017: J7322, Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg

Procedures/Professional Services (And CPT®)

  • Dermal filler injection for LDS
    • 2016: C9800, Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies
    • 2017: G0429, Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)
  • Laryngoscopy with injection
    • 2016: C9742, Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if performed
    • 2017: 31573, Laryngoscopy, flexible; with therapeutic injection(s) (e.g., chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral
    • 2017: 31574, Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral
  • Peri-prostatic material placement
    • 2016: C9743, Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies)
    • 2017: 0438T, Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance

Skin Substitutes and Biologicals

  • PuraPly
    • 2016: C9349, PuraPly, and PuraPly antimicrobial, any type, per square centimeter
    • 2017: Q4172, PuraPly or PuraPly AM, per square centimeter

How About You?

Did you find any good news in the HCPCS 2017 updates?

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3 Things to Know Before Reporting Spine Code 63030

Tue, Jan 17, 2017


63030 lumbar laminotomy


That’s the national Medicare rate for lumbar laminotomy code 63030 in January 2017. To help ensure you collect every dollar you deserve (but not a penny more), keep these three tips in mind for proper reporting.

1. Know How to Count Interspaces

Watch for the word “interspace” at the end of the descriptor for 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar).

Spine coders have to be anatomy aces with a clear understanding of interspace vs. vertebral body to be sure they code correctly.

Example: L1, L2, and L3 add up to three vertebral bodies. But there are only two interspaces, L1-L2 and L2-L3.

You report 63030 per interspace, so be sure you’re counting interspaces and not vertebral bodies.

2. Pick +63035 for Additional Levels

If the surgeon performed the laminotomy procedure described by 63030 on more than one lumbar interspace at the same session, you should not report 63030 twice.

Instead, you should report 63030 for the first interspace and for each additional interspace, report +63035 (… each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]).

Code +63035 has a national Medicare rate of $201.34.  That’s significantly less than 63030, so using the correct code is important to ensure accurate reimbursement that doesn’t lead to payback demands from payers.

Example: If the surgeon performed the laminotomy service on two lumbar interspaces, on the right side. Your coding may look like this, depending on your payer’s modifier reporting preferences:

  • 63030-RT (Right side), 1 unit
  • +63035-RT, 1 unit.

3. Turn to Modifier 50 for Bilateral Service

Both CPT® and Medicare consider 63030 to be a unilateral code, meaning that 63030 represents a service on just one side of the body.

If the surgeon performs the laminotomy service on both sides of the same interspace, you should append modifier 50 (Bilateral service) to 63030 for additional payment. Code +63035 is also unilateral and accepts modifier 50.

Example: If the surgeon performed bilateral laminotomy services on two lumbar interspaces, your coding may look like this, depending on your payer’s modifier reporting preferences:

  • 63030-50, 1 unit
  • +63035-50, 1 unit.

If you’re aware of the CPT® instruction under both 63030 and +63035 to append modifier 50 for a bilateral service, you may think this tip is pretty obvious. But you shouldn’t assume Medicare applies CPT® rules. For instance, 69210 (Removal impacted cerumen requiring instrumentation, unilateral) specifically states unilateral in the descriptor, but Medicare will not pay extra if you append modifier 50.

You can confirm Medicare’s bilateral indicator for a code in the Medicare Physician Fee Schedule. Both 63030 and +63035 have bilateral indicator 1 at the time of this post. Medicare defines indicator 1 this way: “150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.”

How About You?

What do you think is the most challenging aspect of coding spine services?

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